SEC FORM 4 SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
 
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
Stromquist Marty

(Last) (First) (Middle)
C/O NCS MULTISTAGE HOLDINGS, INC.
19450 STATE HIGHWAY 249, SUITE 200

(Street)
HOUSTON TX 77070

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
NCS Multistage Holdings, Inc. [ NCSM ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
X Officer (give title below) Other (specify below)
President
3. Date of Earliest Transaction (Month/Day/Year)
02/15/2019
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock 02/15/2019 A 663,468 A (1) 663,468 I By Corporation(2)
Common Stock 113,443(3) I See Footnote(3)
Common Stock 24,419(4) D
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction Code (Instr. 8) 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Exchangeable Shares(5) (5) 02/15/2019 D 221,155.8 (5) (5) Common Stock 663,468 (6) 0 I See Footnote(3)
Explanation of Responses:
1. Cemblend Systems Inc. ("Cemblend") converted exchangeable shares into shares of common stock of the Issuer and distributed such shares to Stromquist Technologies Inc. ("STI").
2. Held by STI, a corporation of which the Reporting Person is a controlling shareholder. The Reporting Person disclaims beneficial ownership of the Issuer's securities held by STI except to the extent of his pecuniary interest therein.
3. Held by Cemblend. Cemblend is indirectly 50% owned by the Reporting Person. The Reporting Person disclaims beneficial ownership of the Issuer's securities held by Cemblend except to the extent of his pecuniary interest therein.
4. Includes 24,419 restricted stock units which vest in three equal annual installments beginning on March 1, 2019.
5. Represents exchangeable shares in NCS Multistage Inc., a wholly owned indirect subsidiary of the Issuer. Each exchangeable share is convertible into three shares of common stock of the Issuer, subject to adjustment. The exchangeable shares are currently exercisable and have no expiration date.
6. Not applicable.
/s/ Kevin Trautner, attorney-in-fact 02/19/2019
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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